Africa: AIDS Treatment 2.0

Editor's Note

As donor commitment to the fight against AIDS threatens to falter,
UNAIDS, the Joint UN Programme on HIV/AIDS, has issued a new report
with ambitious proposals and an upbeat perspective on the prospects
for advances in both treatment and prevention. Proposing simplified
treatment practices under the rubric "Treatment 2.0," the report
also cites significant advances in prevention, particularly among
African youth, and widespread global awareness of the importance of
the pandemic among issues requiring high priority.

This AfricaFocus Bulletin (at http://www.africafocus.org/docs10/hiv1007a.php) contains the
UNAIDS press release on its new Outlook report, and excerpts from
the report itself on the principles of Treatment 2.0, and the
positive example of successful decentralization and simplification
of treatment in Malawi.

Another AfricaFocus Bulletin, available on the web today at
http://www.africafocus.org/docs10/hiv1007b.php, but not sent out by
e-mail, contains results reports from the Global Fund to Fight
AIDS, TB, and Malaria, including a summary of limited advances by
some African countries in increasing domestic spending on health.

Ten million deaths and 1 million new HIV infections could be
averted if countries meet HIV treatment targets

[Excerpts: For full press release and the report, including
extensive graphs and figures, visit the UN AIDS website.]

New UNAIDS report shows that young people are leading the
prevention revolution, with 15 of the most severely affected
countries reporting a 25% drop in HIV prevalence among this key
population. New global opinion poll shows that AIDS continues to be
of major importance for the public around the world.

Geneva, 13 July 2010 -- The new UNAIDS Outlook report outlines a
radically simplified HIV treatment platform called Treatment 2.0
that could decrease the number of AIDS-related deaths drastically
and could also greatly reduce the number of new HIV infections.
Evidence shows that new HIV infections among young people, in the
15 countries most affected by HIV, are dropping significantly as
young people embrace safer sexual behaviours.

Also in the report, a sweeping new UNAIDS and Zogby International
public opinion poll shows that nearly 30 years into the AIDS
epidemic, region by region, countries continue to rank AIDS high on
the list of the most important issues facing the world.

And an economic analysis makes the case for making health a
necessity, not a luxury, outlining the critical need for donor
countries to sustain AIDS investments and calling on richer
developing countries to invest more in HIV and health.

The report was launched in Geneva ahead of the XVIII International
AIDS Conference in Vienna. The UNAIDS Executive Director, Mr Michel
Sidib‚, stressed that innovation in the AIDS response can save more
lives. "For countries to reach their universal access targets and
commitments, we must reshape the AIDS response. Through innovation
we can bring down costs so investments can reach more people."

According to UNAIDS' estimates there were 33.4 million people
living with HIV worldwide at the end of 2008. In the same year
there were nearly 2.7 million new HIV infections and 2 million
AIDS-related deaths.

Treatment 2.0 saves lives

Treatment 2.0 is a new approach to simplify the way HIV treatment
is currently provided and to scale up access to life saving
medicines. Using a combination of efforts it could bring down
treatment costs, make treatment regimens simpler and smarter,
reduce the burden on health systems and improve the quality of life
for people living with HIV and their families. Modelling suggests
that compared with current treatment approaches, Treatment 2.0
could avert an additional 10 million deaths by 2025.

In addition, the new approach could also reduce new HIV infections
by up to 1 million annually if countries provide antiretroviral
therapy to all people in need, following revised WHO treatment
guidelines. Today, 5 million of the 15 million people in need are
accessing these life-saving medicines.

To achieve the full benefits of Treatment 2.0 progress has to be
made across five areas:

Create a better pill and diagnostics: UNAIDS calls for the
innovation of a smarter, better pill that is less toxic and for
diagnostics that are easier to use. Monitoring treatment requires
complex equipment and specialized laboratory technicians. A simple
diagnostic tool could help to reduce the burden on health systems.
Such a simplified treatment platform could defray costs and
increase people's access to treatment.

Treatment as prevention: antiretroviral therapy reduces the level
of the virus in the body. Evidence shows that when people living
with HIV have lowered their viral load they are less likely to
transmit HIV. It is estimated that ensuring everyone in need has
access to treatment, according to the current treatment guidelines,
could result in up to a one third reduction in new HIV infections
annually.

Optimizing HIV treatment coverage will also result in other health
prevention benefits, including much lower rates of tuberculosis and
malaria among people living with HIV.

Stop cost being an obstacle: despite drastic reductions in drug
pricing over the past ten years, the costs of antiretroviral
therapy programmes continue to rise. Drugs can be even more
affordable--however, potential gains are highest in the area of
reducing the non-drug-related costs of providing treatment, such as
hospitalization, monitoring treatment, and out-of-pocket expenses.
Currently these costs are twice the cost of the drugs themselves.
Treatment 2.0 is expected to reduce the cost per AIDS-related death
averted by half.

Improve uptake of voluntary HIV testing and counselling and
linkages to care: when people know their HIV status they can start
treatment when their CD4 count is around 350, rather than waiting
until they are feeling sick. Starting treatment at the right time
increases the efficacy of current treatment regimens and increases
life expectancy.

Strengthen community mobilization: by involving the community in
managing treatment programmes, treatment access and adherence can
be improved. Demand creation will also help bring down costs for
extensive outreach and help reduce the burden on health care
systems.

"Not only could Treatment 2.0 save lives, it has the potential to
give us a significant prevention dividend," said Mr Sidibé
speaking at the launch of the report.

Young people leading the prevention revolution

A new UNAIDS study shows that young people are leading the HIV
prevention revolution. HIV prevalence among young people has
declined by more than 25% in 15 of the 25 countries most affected
by AIDS. These declines are largely due to falling new HIV
infections among young people.

In eight countries--Côte d'Ivoire, Ethiopia, Kenya, Malawi,
Namibia, the United Republic of Tanzania, Zambia and
Zimbabwe--significant HIV prevalence declines have been accompanied
by positive changes in sexual behaviour among young people.

For example, in Kenya there was a 60% decline in HIV prevalence
between 2000 and 2005. HIV prevalence dropped from 14.2% to 5.4% in
urban areas and from 9.2% to 3.6% in rural areas in the same
period. Similarly in Ethiopia there was a 47% reduction in HIV
prevalence among pregnant young women in urban areas and a 29%
change in rural areas.

Young people in 13 countries, including Cameroon, Ethiopia, and
Malawi, are waiting longer before they become sexually active.
Young people were also having fewer multiple partners in 13
countries. And condom use by young people during last sex act
increased in 13 countries.

There are 5 million young people living with HIV worldwide, making
up about 40% of new infections.

The Benchmark survey

...

Overall, respondents put AIDS as the top health-care issue in the
world. Furthermore, about half of the respondents are optimistic
that the spread of HIV can be stopped by 2015.

...

When asked about how their country was doing against the epidemic,
about 41% of respondents said that their country was dealing
effectively with the problem. Only one in three people believe the
world is responding effectively to AIDS.

...

When it came to HIV treatment, nearly six in ten believe it is the
duty of the state to provide for free or subsidized treatment for
people living with HIV.

Investment in HIV is smart and proven. At this turning point,
flat-lining or reductions in investments will hurt the AIDS
response. In 2010 an estimated US$ 26.8 billion is required to meet
country-set targets for universal access to HIV prevention,
treatment, care and support.

"The AIDS response needs a stimulus package now. Donors must not
turn back on investments at a time when the AIDS response is
showing results," said Mr Sidibé "The 0.7% target on international
aid and the Abuja target of 15% for health cannot be buried."

UNAIDS recommends that national HIV programmes invest between 0.5%
and 3% of government revenue in the AIDS response. In recent years
many countries have increased their domestic investments in the
AIDS response. For example, the South African Government increased
its budget for AIDS by 30% to US$ 1 billion in 2010. However, for
the majority of the countries severely affected by AIDS, domestic
investments alone, even when raised to optimal levels, will not
suffice to meet all their resource needs.

UNAIDS calls on richer developing countries to meet a substantial
proportion of their resource needs from domestic sources.
Currently, 50% of the global resources requirement for low- and
middle-income countries is in 68 countries where the national need
is less than 0.5% of their gross national income. These countries
have 26% of the people living with HIV and receive 17% of
international assistance for AIDS.

According to the report, current investments in HIV can become more
efficient, effective and predictable. "We can bring down costs so
investments can reach more people," said Mr Sidibé "This means
doing things better--knowing what to do, channelling resources in
the right direction and not wasting them, bringing down prices and
containing costs. We must do more with less."

More on the 5 Pillars, from UNAIDS Outlook report

Pillar 1

Creating a better pill and diagnostics

When treatment for HIV first came around in 1996, it was a tough
pill to swallow--literally. It meant on average taking 18 pills a
day, of varying shapes and sizes. Some were taken with food, others
on an empty stomach, and rigorous monitoring of the time of day the
pill was taken was needed in order to mitigate the risk of the virus becoming resistant to
the drugs.

But it worked. People called it the Lazarus effect: people near
death became healthy again.

Antiretroviral therapy works by suppressing the virus and stopping
it from reproducing. If the active component of the drugs is not
kept constant in the body, the virus can mutate, continue to
multiply, and become resistant to the drug. By adhering to a
treatment regimen--for most combinations this means taking the
medication at a given time of day, two to three times a day--drug
levels are kept even.

The more different types of pills a person takes, the more
substances the body has to accustom itself to, the higher the risk
of developing side-effects. Many people living with HIV who have
been on treatment can testify to the side-effects -- from
depression and fever to lipoatrophy (the loosing of fat from
certain areas of the body).

Developing resistance to a regimen is a well-founded fear--once a
regimen is no longer effective, people living with HIV may have to
move to a second-line of treatment.

Access to second-line treatment is still rare in most low- and
low-middle income countries due to the high cost of the pills and
more complex monitoring systems and supply-chain management.

Improving effectiveness and ease of use, and lowering side-effects
and resistance, need to be considered in the development of new
treatment options.

Some regimens already exist as fixed-dose combinations, where
multiple drugs are in one pill, but options that have fewer
side-effects and have less potential for long-term toxicity (dose
optimization, mini-mal requirements for laboratory monitoring) and
that are more resilient and tolerant to treatment interruptions
(to minimize the development of drug resistance) are needed.

In an ideal scenario, having such a pill could do away with the
current need for second- and third-line treatments.

At the same time, simpler diagnostic tools and technologies are in
short supply. Pregnancy tests can be used at home.

People who have diabetes can check their blood glucose level nearly
anywhere. And if a mother is worried that her child has a fever she
has many choices on how to check her child's temperature. All of
these diagnostics are easy to use, usually without the need for a
doctor or a lab.

The same cannot be said currently for checking HIV status or CD4
and viral load testing. While robust rapid tests are more and more
used for the first HIV test, monitoring CD4 counts and viral load
requires expensive and time-consuming lab-based tests.

Treatment monitoring that is closer to the patient can lead to
better treatment results. It can facilitate early detection and
treatment of HIV and can ensure appropriate and rapid response to
drug resistance, improving outcomes for people on treatment and
reducing the development and spread of drug-resistant strains of
the virus.

Pillar 2

Treatment as prevention

Since 1991, the world has known that effective antiretroviral
therapy can help to prevent HIV transmission. This has been the
case for vertical transmission, for example ensuring that pregnant
women living with HIV don't pass on the virus during pregnancy or
childbirth.

Recently, however, the dramatic impact of treatment on other forms
of HIV transmission has become better understood. Evidence clearly
shows that successful viral suppression through treatment can
substantially reduce the risk of vertical, sexual and blood-borne
HIV transmission.

A recent study, supervised by the University of Washington and
largely funded by the Bill & Melinda Gates Foundation looked at
3400 heterosexual couples--each with one HIV-positive and one
HIV-negative person--from seven countries in sub-Saharan Africa.
When the HIV-positive partner was on treatment, the researchers
found the HIV transmission rate was 92% lower than among couples
where the person living with HIV did not receive treatment.

This study also confirmed that a significant proportion of all HIV
transmission happens during the phase when people living with HIV
develop increasing immune impairment (which is marked with
increasing viral load and decreasing levels of CD4 counts).

Treatment can become part of a combination prevention strategy.
Optimizing treatment coverage will also result in other prevention
benefits, including lower rates of tuberculosis.

Treating everyone in need of treatment according to current
treatment guidelines could result in a one third reduction in new
infections globally.

Further research is urgently needed in order to better understand
the possibilities and role of antiretroviral therapy in earlier
asymptomatic phases of HIV infection.

Pillar 3

Stop cost being an obstacle

Despite drastic reductions in drug pricing over the past ten years,
the costs of antiretroviral therapy programmes continue to rise.

The reported proportion of people on second-line regimens remains
low. In 2008, a vast majority of adults (98%) and children (97%)
surveyed in 43 high-burden countries were receiving first-line
antiretroviral therapy regimens.

In low- and middle-income countries, the average annual cost of the
most widely used first-line drug treatments was US$143 per person
in 2008, a price reduction of 48% since 2004. There was an even
greater price reduction in paediatric formulations, from US$ 436
per person per year in 2004 to US$ 105 in 2008. This all helped to
contribute to a wider availability of treatment. Second-line
regimens continue to be more expensive.

Drugs can be even more affordable--however, potential gains are
highest in the area of reducing the non-drug-related costs of
providing treatment. Currently these costs significantly outweigh
the cost of the drugs themselves.

Cost savings can be found in every step of the process. A better,
singe-dose pill with decreased toxicity and that was
resistant-proof would have fewer needs for treatment

monitoring. This would lead to a reduced number of interactions
with health-care providers--less health-care time spent on
monitoring people enrolled on antiretroviral therapy programmes
frees up resources to be devoted to other pressing health issues.

A decreased frequency of interaction with health-care providers
also lowers out-of-pocket costs, such as transport fees, for the
care seeker.

Simplified treatment and diagnostic approaches would allow for the
decentralization of services from specialized health systems to
primary and community health-care providers, where antiretroviral
therapy administration and monitoring moves from doctors to nurses
and community health-care workers.

These simplified approaches will also ensure that investments in
HIV treatment directly benefit the delivery of other health
programmes, as they happen through the same health-care sites and
with the same health-care workers. Infrastructure investments and
training benefit more efficiently the delivery of broader health
services.

Pillar 4

Improve uptake of HIV testing and linkage to care

The uptake of HIV testing and counselling and linkage to care will
need to be improved drastically if the promise of treatment and
treatment-centred HIV prevention approaches are to be realized.

Globally only about 40% of people living with HIV know their HIV
status--the large majority of whom find out they have HIV by
developing clinical AIDS, with their immune system already
seriously weakened.

Stigma and discrimination remain as the foremost impediment to HIV
testing utilization. For many people even seeking out HIV testing
can lead to serious, even life-threatening, exposure to violence,
legal action and loss of family, employment, and property. And
where care, treatment and support services are unavailable, there
is little incentive to take an HIV test.

However, progress is being made. South Africa is scheduled to reach
15 million people in two years. In the United Republic of Tanzania,
three million people received HIV tests in six months; in Malawi
200 000 people took HIV tests in one week.

Community-based organizations, often led by people living with HIV,
provide an important and effective bridge into HIV testing and a
link to treatment and prevention services. Peer-based services are
often more trusted than government-led services, especially by
populations at higher risk, which can be fearful of government-run
health-care approaches.

The results of programmes from countries as diverse as Bolivia,
Botswana, China, India, the Russian Federation,
Rwanda and Uganda all show the positive impact that individual
engagement with community-based services has on
increased HIV testing rates and increased use of HIV prevention and
treatment services, as well as improved treatment adherence and
prevention practices and a reduction in stigma.

We need to learn from and scale up successful models of partnership
between health service providers and community-

based service providers to assist in stigma reduction and increased
utilization of services in particular by populations at higher
risk. Many examples exist in countries, including programmes that
receive support from the United States President's Emergency Plan
for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and
Malaria (Global Fund).

Pillar 5

Strengthen community mobilization

Drug users, men who have sex with men, sex workers and poor women
often have little reason to trust government-provided health
services. Fear of exposure of their HIV status keeps many people
from seeking HIV testing and health services.

Community-based approaches to build trust, protect human rights and
provide opportunities for socialization directly improve the
ability of people to use HIV services and to benefit from
antiretroviral therapy and prevent new infections. In fact, much of
the success to date in the AIDS response is due to the
unprecedented engagement of affected communities as advocates,
educators and service providers.

In the late 1980s, TASO (the AIDS Support Organization) developed
models for community-based support services in Uganda that were
duplicated all over the world.

Grupo Pela Vidda in Brazil successfully helped advocate for full
antiretroviral therapy coverage in the country, which led to a 50%
drop in AIDS-related deaths in one year.

Work by AIDS activists in the United States of America helped to
cut the time its takes to approve new drugs for life-threatening
illnesses in half, leading to the early approval and availability
of highly active antiretroviral therapy in 1996, saving millions of
lives.

...

The Treatment Action Campaign in South Africa successfully
confronted a government that failed to address the most destructive
HIV epidemic in the world, leading to the development of treatment
access programmes throughout the country and an increased
commitment to HIV testing and prevention.

Simplified approaches to treatment offer unique opportunities to
increase community-based delivery of outreach and support services,
with direct positive effects for prevention and for lower-cost
treatment.

Decentralizing HIV treatment in Malawi

According to government sources, nearly 200 000 people living with
HIV in Malawi were accessing antiretroviral therapy in 2009, up
from about 10 000 in 2004. Between 2003 and 2009, the number of
sites in Malawi providing antiretroviral therapy increased from
nine to 377. A decentralized approach to HIV treatment and care was
critical to this national success in antiretroviral therapy
scale-up.

Under Malawi's first national antiretroviral therapy guidelines of
2003, only doctors and clinical officers--based primarily at larger
health facilities in urban settings--were empowered to start
patients on antiretroviral therapy. Medical assistants and nurses
could monitor and follow up on a patient's progress, but were not
able to prescribe treatment.

With about 85% of the population in Malawi living in rural areas,
treatment access became an important issue. "Some people had to
travel 100 kilometres to be assessed if they were eligible for
antiretroviral therapy," says Professor Anthony Harries, an adviser
to the Malawian government's HIV programme from 2003 to 2008.
"Though this was a free service, it meant time away from work.
Those who did manage to access antiretroviral therapy had great
difficulty continuing treatment because of the cost of transport."

Malawi's new antiretroviral therapy scale-up plan (2006-2010)
included a number of strategies to bring HIV treatment closer to
the primary point of care, where the majority of the population
lives. Under the new guidelines, medical assistants and nurses were
empowered to initiate antiretroviral therapy--from 2006 and 2008,
respectively.

In partnership with the Ministry of Health and district-level
medical facilities, many community-based health centres were
accredited as antiretroviral therapy delivery clinics. About 88 000
people started antiretroviral therapy in 2009 alone. Of the 377
sites in Malawi in which antiretroviral therapy is now offered,
more than 50% are simple health centres.

"Through this decentralized approach, we were able to reach out
into the communities, where people otherwise could not access
treatment," says Dr Frank Chimbwandira, Director of the HIV/AIDS
Department in Malawi's Ministry of Health. "We were also able to
improve treatment follow-up, as more people could come back and
forth from the health centres to access their medication."

AfricaFocus Bulletin is an independent electronic publication
providing reposted commentary and analysis on African issues, with
a particular focus on U.S. and international policies. AfricaFocus
Bulletin is edited by William Minter.

AfricaFocus Bulletin can be reached at africafocus@igc.org. Please
write to this address to subscribe or unsubscribe to the bulletin,
or to suggest material for inclusion. For more information about
reposted material, please contact directly the original source
mentioned. For a full archive and other resources, see
http://www.africafocus.org